Assembly for augmenting hard tissue

ABSTRACT

An augmentation method is provided, wherein a thermoplastic augmentation element is subject to mechanical energy impact and mechanical pressure by a tool so that augmentation material of the augmentation element is liquefied and pressed into hard tissue to augment the hard tissue, wherein in at least one axial depth, the augmentation element is segmented as a function of the circumferential angle so that at this axial depth the circumferential wall of the initial opening in first regions is in contact with the augmentation element and in second regions is not in contact with the augmentation element.

BACKGROUND OF THE INVENTION

Field of the Invention

The invention is generally in the field of medical technology and, inparticular, relates to medical devices, medical apparatus and medicalmethods, and especially to implants, apparatuses for implantation, andimplantation methods.

Description of Related Art

If screws are anchored in live bone tissue, for example of thevertebrae, the mandible, the maxilla (for dental implants) or other bonetissue, often the problem of insufficient bone stability or insufficientstability of the anchoring in the bone arises. Especially, in trabecularbone tissue, any load acting on the screw is passed over to only fewtrabeculae, with adverse consequences both for the load bearingcapability of the screw-bone connection and for its long-time stability.This is especially severe in osteoporotic or osteopenic or otherwiseweakened bone tissue.

WO2010/045751 discloses a method of anchoring an implant in hard tissueand/or hard tissue replacement material. The method includes compressinga thermoplastic augmentation element between a tool and a counterelement while mechanical energy is coupled into the tool so thatthermoplastic material of the augmentation element is liquefied andpressed into surrounding tissue. In this process, for compressing theaugmentation element a tensile force is coupled into the tool, and thetool is pulled towards a proximal direction.

While this method is advantageous in many situations, it is restrictedto situations where the tool may be introduced into a comparably largeinitial opening.

SUMMARY OF THE INVENTION

It is an object of the present invention to provide methods for improvedanchoring stability of surgical implants in bone tissue. It is aparticular object to provide a method of augmenting hard tissue and/orhard tissue replacement material for later insertion of a surgicalimplant, such as a surgical screw or an implant weldable to theaugmentation material. It is a further object of the present inventionto provide according devices. It is yet another object to provideimplantation methods that include augmenting the tissue.

In accordance with a first aspect of the invention, a method ofaugmenting hard tissue and/or hard tissue replacement material forinsertion of an implant, an according device, and an implantation methodincluding such an augmenting method are provided.

In accordance with the method of the first aspect the augmentationmethod includes the steps of:

-   -   providing an initial opening in the hard tissue and/or hard        tissue replacement material;    -   providing a thermoplastic augmentation element and a tool;    -   placing the augmentation element in the initial opening, placing        the tool in contact with an end face of the augmentation element        and pressing the tool against the end face while energy is        coupled into the tool and while a periphery of a liquefaction        interface of the tool and the augmentation element is within the        opening;    -   thereby liquefying material of the augmentation element at the        liquefaction interface(s) to yield liquefied material;    -   causing portions of the liquefied material to penetrate into        structures of the hard tissue and/or hard tissue replacement        material;    -   allowing the liquefied material to harden and to thereby become        augmentation material; and    -   removing the tool;    -   wherein at least one of the following conditions is fulfilled:    -   a. in at least one axial depth, the augmentation element is        segmented as a function of the circumferential angle so that at        this axial depth the circumferential wall of the initial opening        in first regions is in contact with the augmentation element and        in second regions is not in contact with the augmentation        element;    -   b. in at least one axial depth of a resulting, augmented        opening, the augmentation material is caused to be segmented as        a function of the circumferential angle;    -   c. in a resulting, augmented opening, the augmentation material        is provided in at least two augmented regions axially spaced        from each other, wherein between the two augmented regions there        is a non-augmented region;    -   d. the augmentation element does not have the symmetry of a        rotational cylinder but is asymmetric with respect to rotation        around any axis.

Also according to the first aspect of the invention, an assemblyincluding the augmentation element and the tool is provided, theassembly being capable of carrying out the above-defined method.

Therein, the end face of the augmentation element may be a proximal endface, and in the step of pressing the tool against the end face whileenergy is coupled into the tool, the tool may be pressed towards adistal direction against the proximal end face of the augmentationelement.

In accordance with an alternative version (in a ‘rearward’configuration), the end face of the augmentation element may be a distalend face, the tool may include a proximally facing shoulder, and in thestep of pressing the tool is pressed towards a distal direction, i.e.the tool is pulled (a tensile force is coupled into the tool).

In rearward configurations (this pertains to all embodiments and aspectsof the invention in which a tensile force is coupled into the tool),especially if the energy coupled into the tool is mechanical vibrationenergy, the tool may include a cable and a distal element attached tothe cable, the distal element forming a proximally-facing coupling-outface that may interface with a distally-facing distal coupling-in faceof the augmentation element. Such a configuration makes possible toaugment tissue also in situations where access with stiff tools would bedifficult, and deflections of the mechanical energy become possible.According embodiments are yet described in more detail referring to thefifth aspect of the present invention. Similarly, also radiation energycan be deflected in this manner, if the cable includes or forms at leastone flexible radiation conductor.

In the present text, embodiments of the first aspect as well as of thehereinafter described second aspect are sometimes referred to asembodiments of segmented augmentation.

After removal of the tool, there will be an augmented opening in thehard tissue/hard tissue replacement material, in which opening animplant may be anchored in a later step. The augmented opening maycorrespond to the initial opening, with a potential slight reduction ofthe cross section due to augmentation material anchored in lateral wallsof the initial opening. In alternative embodiments, further steps ofmodifying the initial opening may be part of the method so that theaugmented opening, at least in certain axial depths (especially at moreproximal positions) has a larger cross section than the initial opening.In many embodiments, however, the augmented opening will not besubstantially larger than the initial opening.

In examples of the first aspect, an auxiliary element that may alsoserve as a counter element is used to guide the augmentation elementand/or to exert a counter force. The auxiliary element may, for example,include a guiding shaft and a distal broadening (foot) that forms ashoulder facing to the proximal side so that a distal end face of theaugmentation element may be pressed against the shoulder when the toolis pressed against the distal direction.

In condition a., the second regions are substantial. For example atleast 60°, or at least 100° or even at least 180° of the overallcircumference is taken up by the second regions. Condition a. impliesthat the surface comprises, in addition to first regions withaugmentation material, also extended second regions without augmentationmaterial.

In condition a., according to an option, the segmentation is such thatit goes along a substantial part of its axial length, for example alongat least 50% of its axial length. It may go essentially along the fullaxial length of the augmentation element, i.e. there are circumferentialangles that are free of augmentation material (or, where there is nocontact between the circumferential wall and the augmentation element)along the full axial length. Especially, the augmentation element mayinclude segments that are entirely separate from each other.Alternatively, such segments may be connected by bridge portionsconnecting them for example at the proximal end and/or the distal end.Such bridge portions may be chosen to be unsubstantial, i.e. the amountof material of the bridge portions may be chosen to be by far lower thanthe material between the bridge portions (for example less than 5% orless than 3% or 2% of the total amount).

In condition b. the distribution between augmented and not augmentedregions along the circumference is determined by the method and the useddevices, i.e. is systematic. This means that the used devices and/or theused method are chosen so that segmentation is achieved in a purposefulmanner; in most cases (unless anatomy prevents this) the surgeon caninfluence where the augmented and non-augmented regions are finally tobe by choosing an appropriate orientation around an augmentation axis.

A method satisfying condition b. may be, according to a firstpossibility, achieved by using a segmented augmentation elementaccording to condition a. In accordance with a second possibility, theinitial opening that is made prior to the step of causing liquefiedaugmentation material to penetrate into the hard tissue and/or hardtissue replacement material, may have a geometry different from thegeometry of the augmented opening. The initial opening may for examplehave a different symmetry than the augmented opening. The step ofcausing liquefied augmentation material to penetrate into the hardtissue and/or hard tissue replacement material may then include causingthe liquefied material to penetrate into lateral walls of the initialopening, in a segmented or non-segmented manner. Subsequently to thisstep, a further (in addition to making the initial opening) materialremoving, for example drilling step is made, in which tissue withaugmentation material is removed, so that the augmented openingsatisfies condition b. For example, the augmentation element and toolsused (such as a sonotrode and possibly a guiding element for theaugmentation element) may have an according, non-circular symmetry.

The augmented opening resulting after augmentation may thus, accordingto a first possibility, be the initial opening with tissue/tissuereplacement material provided by the augmentation material in theaugmented regions. In accordance with a second possibility, which can becombined with the first possibility, the resulting opening may be causedby drilling into the initial opening that has tissue/tissue replacementmaterial provided with augmentation material. For example, the initialopening may be such as to not have rotational symmetry with respect toan opening axis, and after the process of pressing the augmentationmaterial into the tissue, a further opening forming step (for example, adrilling step) may be made so that tissue with the augmentation materialis removed in certain regions. The further opening forming step may bemade by means of a tool that makes circular cylindrical bores, such as adrill.

Condition b. may, for example, be achieved either by a segmentedsonotrode, by material removal in accordance with the second possibilityabove, or by other means such as using a plurality of augmentationelements and prior to or after forming the opening.

For condition c., the augmentation process, for example as describedhereinbefore (with or without segmentation) or described hereinafter ordescribed in WO 2010/045751 incorporated herein by reference in itsentirety may be carried out at different axial depths. Alternatively, anauxiliary element having an opening accessible from the proximal sideand with material exit holes may be used, wherein the material exitholes define the locations where the tissue is augmented. Other variantsare possible.

Axial segmentation in accordance with condition c. has the advantagethat the augmentation process may be adapted to particular physiologicalboundary conditions. Also, the regions that are not augmented mayprovide a faster healing, depending on the tissue quality.

In accordance with condition d., the augmentation element may especiallyhave an outer contour shape (in a cross section perpendicular to theaxis) that is essentially triangular, rectangular, star-shaped, etc.(all with rounded corners) etc. Circumferential segmentation (to satisfycondition b.) may be achieved by subsequently drilling, in accordancewith the second aspect described hereinafter, a cylindrical hole, thedrill having a diameter greater than a minimal outer diameter of theaugmentation element but smaller than a maximal outer diameter of theaugmented tissue/tissue replacement material.

All of the conditions a.-d. can be combined with each other, i.e. ab,ac, ad, bc, bd, cd, abc, abd, acd, bcd, and abcd.

In accordance with a second aspect, the augmentation method ofaugmenting hard tissue and/or hard tissue replacement material includesthe steps of:

Providing at least one thermoplastic augmentation element;

Placing the augmentation element in contact with the hard tissue and/orhard tissue replacement material and causing mechanical energy toimpinge on the augmentation element to liquefy at least portions of theaugmentation element and causing liquefied augmentation materialportions of the augmentation element to penetrate into the hard tissueand/or hard tissue replacement material;Letting the liquefied augmentation material portions re-solidify;Removing a portion of the hard tissue and/or hard tissue replacementmaterial and of the re-solidified augmentation material, whereby anaugmented opening is obtained, the augmented opening having surfaceportions of the hard tissue and/or hard tissue replacement material withthe re-solidified augmentation material and having surface portions ofthe hard tissue and/or hard tissue replacement material without there-solidified augmentation material.

The removing step may be made by means of a tool that makes circularcylindrical bores, such as a drill.

In a first group of embodiments, prior to the step of causing liquefiedaugmentation material to penetrate into the hard tissue and/or hardtissue replacement material, an initial opening of a geometry differentfrom the geometry of the augmented opening is provided, the initialopening for example having a different symmetry than the augmentedopening. The step of causing liquefied augmentation material topenetrate into the hard tissue and/or hard tissue replacement materialmay then include causing the liquefied material to penetrate intolateral walls of the initial opening. For example, the augmentationelement and tools used (such as a sonotrode and possibly a guidingelement for the augmentation element) may have an according,non-circular symmetry.

The subsequent step of removing a portion of the hard tissue and/or hardtissue replacement material and of the re-solidified augmentationmaterial then may divide the augmentation material into segments, thesurface portions of the hard tissue and/or hard tissue replacementmaterial without the re-solidified augmentation material being betweenthe segments.

In a second group of embodiments, the augmentation element or aplurality of augmentation elements may be caused to be anchored in thetissue by a method as described in U.S. Pat. No. 7,335,205, which isincorporated herein by reference in its entirety. For example, aplurality of essentially pin-like augmentation elements may be used. Theaugmentation elements are anchored at positions that are peripheral withrespect to the later added augmented opening. Thereafter, the augmentedopening is made, the augmented opening, for example, being cylindricalor conical or having an elliptical or any other shape.

In embodiments of the first and/or second aspect, the initial openingand/or the final, augmented opening may be stepped, i.e. its crosssection may vary as a function of the depth, with a step-like dependencyof the cross section on the axial position.

Embodiments of the first and/or second aspect of the invention mayprovide the following advantage: A non-segmented augmentation with acontiguous, tube-shaped augmentation element would lead to a toroidalaugmentation material distribution in the bone material. If subsequentlya screw is screwed into the augmented initial opening, the material willbear a substantial resistance, and this may lead to a torsional movementof the whole toroidal augmentation material ring within the bone tissueleading to a damage to the trabeculae of the cancellous bone. Incontrast thereto, the segmented augmentation material can give way tosome extent due to the residual elasticity of the bone tissue, and thiswill ease screwing in of the screw, while the additional stabilityprovided by the augmentation can be benefited from.

In accordance with a third aspect of the invention, a method ofaugmenting hard tissue and/or hard tissue replacement material isprovided, which method including augmenting the tissue afterimplantation of the implant. To this end, after implantation of theimplant (for example conventionally, by drilling a hole and thereafterpressing or screwing the implant into the hole; or by a method asdisclosed in U.S. Pat. No. 7,335,205), at least one augmentation elementis anchored, under the impact of energy, in the tissue to be in contactwith the implant. The implant and the augmentation element may, inaccordance with a first possibility, include structures so that theyserve as base part and based part in the sense of the teaching of US2010/0 023 057 incorporated herein by reference in its entirety so thatthe implant and the augmentation element interlock after the process. Inaccordance with a second possibility, the implant and the augmentationelement both include thermoplastic material so that the augmentationelement is weldable to the implant.

In accordance with the method of the fourth aspect, the augmentationmethod includes the steps of:

-   -   providing an initial opening in the hard tissue and/or hard        tissue replacement material;    -   providing a thermoplastic augmentation element (for example        being a sleeve with a sleeve wall), and further providing a tool        (for example sonotrode) and an auxiliary element;    -   placing the augmentation element in the initial opening, the        augmentation element at least partially encompassing a guiding        portion of the tool or of the auxiliary element,    -   coupling a pressing force and energy into the tool and from the        tool into the augmentation element while a portion of the        augmentation element is within the opening and in contact with        the hard tissue and/or hard tissue replacement material;    -   thereby liquefying material of the augmentation element to yield        liquefied material;    -   causing portions of the liquefied material to penetrate into        structures of the hard tissue and/or hard tissue replacement        material and/or into structures of an element connected to the        hard tissue and/or hard tissue replacement material;    -   allowing the liquefied material to harden and to thereby become        augmentation material; and    -   removing the tool;    -   wherein at least one of the following conditions is fulfilled:        -   A. during the step of coupling a pressing force and energy            into the tool, an outer protection element at least            partially encompasses the tool and locally prevents the tool            from being in contact with the hard tissue and/or hard            tissue replacement material;        -   B. the augmentation element is generally sleeve-shaped and            includes at least one indentation or hole in a sleeve wall;        -   C. during the step of coupling a pressing force and energy            into the tool, in a telescoping region a portion of the tool            encompasses a portion of the auxiliary element or a portion            of the auxiliary element encompasses the tool, wherein the            tool and/or the auxiliary element comprises/include at least            one protrusion facing to the auxiliary element/tool,            respectively, so that in the telescoping region a contact            between the tool and the auxiliary element is prevented,            except for the protrusion/protrusions;        -   D. during the step of coupling a pressing force and energy            into the tool, the tool is pressed towards the distal            direction, and wherein the tool includes a distal broadening            forming an salient feature that prevents a contact between            the tool and the hard tissue and/or hard tissue replacement            material at locations proximally of the salient feature            (i.e. the diameter of the tool is, except for the salient            feature, reduced compared to the diameter of the initial            opening);        -   E. prior to the step coupling a pressing force and energy            into the tool, the augmentation element is connected to the            tool by an axial positive-fit connection, and during the            step of coupling a pressing force and energy into the tool,            the auxiliary element is pressed against a distal direction            to activate the step of liquefying material of the            augmentation element and to push portions of the liquefied            material aside and into the structures of the hard tissue            and/or hard tissue replacement material.

At least the following combinations of these conditions are possible andare further embodiments of the invention: AB, AC, ABC, BC, BD, BCD, CD,CDE, DE. In addition, in special configurations also BE, BCE, and BCDEare possible.

In this, as well as in the other aspects of the invention, the energymay be coupled into the tool (and from there into the augmentationelement) in the form of mechanical vibrations.

Alternatively, the energy may be coupled into the tool by way ofradiation (especially laser radiation) that is absorbed by theaugmentation element. As yet another alternative, the energy may bemechanical energy different from mechanical vibration, for examplerotation. As an even further alternative, the energy may be heat, forexample directed to the augmentation element by heat conduction and/orby causing an electrical current to flow through the augmentation whilethe latter includes electrically conducting material with a relativelyhigh electrical resistance.

In embodiments in which the energy coupled into the augmentation elementis radiation energy, the tool has waveguiding properties and is equippedfor coupling the radiation into the augmentation element. The tool may,for example, be an optical fiber or a bundle of optical fibers or mayhave integrated light guiding elements. The augmentation element inthese embodiments is equipped for absorbing the radiation coupled intoit, either at the interface or in the augmentation element body, orboth. To that end, the augmentation element may be of an essentiallytransparent material, provided with pigments, or similar absorbing theradiation.

In condition A, the outer protection element may be a sleeve of asuitable material and having suitable surface properties to minimizefriction between the tool and the protection element. Especially, it maybe a thin sleeve, the material thickness being merely sufficient so thatthe protection element is dimensionally stiff. The protection elementprevents the tool from being in contact with the tissue locally, at theplace of the protection element. At other places, direct contact betweentool and tissue may occur depending on the situation.

In condition A, optionally the protection element may include threadtapping functionality.

In condition B, the augmentation element may be generally sleeve-shapedbut with the indentations, holes or the like being systematicweakenings. Due to these weakenings—that may be arranged as spacesadapted to the purpose of the augmentation element and/or the anatomicalcircumstances of the tissue to be augmented—the augmentation materialmay be liquefied with less energy impact. Onset of liquefaction as afunction of the power that impinges on the augmentation element isalready at lower powers, so that less power is required to liquefy. Inembodiments, the weakenings are grooves that are inclined with respectto a radial direction. The grooves define necks in the augmentationelement material at which the liquefaction sets in when energy impinges.After liquefaction at the necks (or other weak points), the remainingpieces may be subject to a shear movement along the direction defined bythe grooves. In embodiments, the grooves are such that the more proximalportions are pressed outwardly when the tool presses them towards thedistal direction.

In this, the holes may, for example, be arranged to formaxially-oriented slits or axially-oriented rows of separate holes.

In embodiments of all aspects, the surface of the tool (for examplesonotrode if the energy impinges through mechanical vibration) that isin contact with the augmentation element and through which themechanical energy is coupled into the augmentation element may begenerally flat (radial, i.e. perpendicular to the proximodistal axis) ormay be tapered or have any other shape. A particularly advantageouscombination is the combination of an augmentation element fulfillingcondition B. with a flat tool contact face. One reason for this is thatthe design and handling of the tool is easier when the surface is flat,while the advantages of non-flat contact faces (namely, direct, targetedonset of liquefaction, displacement of the liquefied material into thetissue) can be achieved also if condition B. is fulfilled.

In condition C, in the telescoping region (where the tool and theauxiliary element are in sliding contact), the tool may include inwardprojections, such as (axial and/or circumferential) ridges, spheres,etc. In addition or as an alternative, the auxiliary element may includecorresponding outward projections. Due to these projections, a volume(buffer volume) remains between the tool and the auxiliary element sothat, with the exception of the protrusions, they do not touch eachother. This reduces energy loss, noise (if the energy is mechanicalenergy, for example vibration energy) and impinging on the tissue. Theprotrusions may be such that liquefied material does not penetrate intothe buffer volume. This may, for example, be ensured that any remaininggap between the sonotrode and the auxiliary element at the interface tothe augmentation element is small enough so that surface tension andheat flow induced quenching of the polymer prevents liquefied materialfrom entering into such a gap. Typically, the upper limit for the gapsize is 0.05 to 0.1 mm for polymer of low melt viscosity (e.g.amorphous, polylactides, i.e. p-L-DL-lactide 70/30 (Resomer LR706,Evonik Germany) or up to 0.2 mm for polymer with a higher melt viscosity(e.g. p-LLA (Resomer L210, Evonik Germany)). The optimal gap width canbe determined in simple size variation experiments.

From the above, it follows that it is often advantageous if the gap issmaller than 0.2 mm so that surface tension prevents liquefied materialfrom entering into such a gap.

Especially, in an embodiment the tool includes an inwardly protrudingdistal circumferential ridge. In another embodiment, the tool and/or theauxiliary element includes a plurality of axial ridges or a plurality ofmicro-protrusions that may be calotte-shaped, conical or have othershapes, including identical and different shapes.

In condition D, the tool comprises, in addition or as an alternative tothe protrusions defined by condition C, at least one outward protrusionthat keeps a body of the tool from getting in direct contact with thetissue. Especially, such outward protrusion may be located essentiallyat the distal end of the tool and at the interface to the auxiliaryelement to thereby prevent liquefied material from flowing back alongthe tissue instead of being pressed into the tissue.

Like in all other embodiments, the feature of condition D may becombined with a slanted distal tool surface.

In condition E, the positive-fit connection may for example be providedby an outer thread of the tool or by circumferentially runningindentations onto which the augmentation material was cast during themanufacturing process. When proceeding in accordance with condition E.,the surgeon may advance the auxiliary element into the distal direction,while the tool is held still, slowly retracted towards the proximaldirection, or slowly moved into the distal direction also (slower thanthe auxiliary element).

Condition E features the first advantage that due to the configurationwith the central tool and the peripheral auxiliary element, there isonly minimal contact between the tool and the tissue surrounding theinitial opening. It features the further advantage that the augmentationelement is coupled to the tool. Therefore, if the energy is mechanicalenergy, the augmentation element is subject to the full (vibratory,rotational) movement—in contrast to configurations where the tool forexample ‘hammers’ onto the augmentation element. This brings about anadditional reduction of the noise caused, as well as of energy requiredfor liquefaction. Also in embodiments where the energy is not mechanicalenergy but for example radiation energy or heat, the direct contact maybe advantageous, especially for optimizing the desired energy transferinto the augmentation element.

If the energy is mechanical vibration energy, the tool is a sonotrodefor coupling the mechanical vibrations and/or heat absorbed from thesevibrations into the augmentation element.

In addition or as an alternative, other measures for noise reduction maybe taken. As an example, the material of the sonotrode and/or theauxiliary element may be chosen so that it may not form a resonatingbody but is—given the chosen frequencies and dimensions, to beconsidered as an essentially stiff body (i.e. the wavelength of thevibrations in the body is substantially larger than its dimensions). Anexample of such a material is PEEK instead of a metal. Other examplesinclude further high temperature melting polymers likePolytetrafluoroethylene (PTFE), polyimides, etc.

In accordance with a fifth aspect of the invention, a device fordeflecting mechanical oscillations is used to cause a sonotrode tooscillate, which sonotrode serves as a tool for coupling energy into theaugmentation element in an augmentation process. In this, theaugmentation process may especially include:

-   -   providing an initial opening in the tissue;    -   providing the augmentation element, and providing a tool;    -   placing the augmentation element in the initial opening, placing        the tool in contact with a face of the augmentation element and        pressing the tool against the face while vibration energy is        coupled into the tool and while a periphery of a liquefaction        interface of the tool and the augmentation element is within the        opening;    -   thereby liquefying material of the augmentation element at the        liquefaction interface(s) to yield liquefied material, causing a        relative movement of the tool with respect to the augmentation        element, and causing portions of the liquefied material to        penetrate into structures of the tissue;    -   allowing the liquefied material to harden and to thereby become        augmentation material; and    -   removing the tool.

In embodiments, at the liquefaction interface a full cross section ofthe augmentation element is liquefied.

The augmentation element may be essentially sleeve-shaped with an axiallumen.

In accordance with the fifth aspect of the invention, the mechanicalvibrations the oscillations are deflected from oscillations along afirst axis at an oscillation generating apparatus (which for exampleincludes an ultrasonic transducer) to oscillations along a second axisat a location of the tool where it forms the interface.

According to a first option, to this end an arrangement for carrying outthe method includes a solid oscillation deflector. This oscillationdeflector may be an oscillation element that is elongate and bentbetween two ends and on which a coupling-in point and a coupling-outpoint are arranged, such that the oscillation element oscillatestransversally at the coupling-in point and at the coupling-out point,when the coupling-in point is subject to an oscillation. Alternatively,this oscillation deflector may be a ring resonator with a coupling-inpoint and a coupling-out point at different locations on the ring.

According to a second option, the tool includes a flexible, bendableregion, namely a cable that deflects the mechanical oscillations. Inaccordance with this option, the force for pressing the tool against theinterface to the augmentation element is coupled into the tool as atensile force, i.e. the method is carried out in a rearwardconfiguration. In addition to the cable, tool also includes a footcoupled to the cable, the foot forming a proximally-facing face thatserves as the coupling-out face of the tool that during the process isin contact with a distal face of the augmentation element, so that thecoupling-out face and the distal face together form the interface.

In this text, the term “cable” is not meant to be restricting as to thematerial or the structure. Especially, the cable may be a wire, a wirerope, a filament, etc., all of a metal, or alternatively of a differentmaterial suitable for forming a cable.

In embodiments of the second option, the axial lumen of the augmentationelement then is through-going with the cable reaching through the axiallumen.

In addition to the tool, the arrangement for carrying out the methodalso includes a diverting feature for the cable, such as a reel or arounded diverter edge. The cable is guided along this diverting feature.

The diverting feature may especially be mounted to the vibrationgenerating apparatus (especially to a housing thereof).

More particularly, the vibration generating apparatus may include avibration generating module, for example with a piezoelectrictransducer, for generating the vibrations (for example ultrasonicvibrations), a cable attached to the vibration generating module, thevibration generating module being movable along a first moving axiswithin the housing of the apparatus, which first moving axis maycorrespond to the first axis of the oscillations (which may belongitudinal oscillations in the cable). The cable exits the housing atan exit location.

The vibration generating apparatus then may further include a divertingfeature arranged or arrangeable at a distance to the exit location. Thediverting feature may be arranged so that the cable is kept along astraight line from the vibration generating module to the divertingfeature, or it may be deflected between the diverting feature and thevibration generating module, for example at the exit location. Thediverting feature may be mounted to the housing fixedly, or movably, forexample extendibly.

As an alternative to being mounted to the housing, the diverting featuremay be present as a separate part, for example a diverting tool held bythe operator or an assistant during the process.

From the diverting feature to the foot, the cable is kept stretchedalong a second, different moving axis, which second axis may correspondto the second axis of the oscillations.

The angle between the first axis and the second axis may be chosendepending on the needs. For dental applications, it is oftenadvantageous if the angle is about 90° or slightly larger than 90°(where the angle is defined so that 180° means “no deflection”), forexample between 90° and 125°. For other surgical applications, the anglemay be different; also angles smaller than 90° are readily feasible.

The counter element, that serves for applying, for example to theproximal end face of the augmentation element, a counter force to theaugmentation element (i.e., the augmentation element is, during theprocess, compressed between the foot and the counter element), mayaccording to a first option also be mounted to the housing. Theapparatus then defines the deflection angle at least approximately.

According to a second option, the arrangement may include a separatecounter element. Then, the operator may choose the deflection anglein-situ and adjust it if necessary during the process.

For the process, the vibration generating module is retracted within thehousing, whereby the cable is pulled to pull the foot along the secondaxis. The retracting movement may be carried out manually orautomatically, for example with the aid of a spring mechanism ormotorized. Thereby, augmentation material of the augmentation element isliquefied, for example, starting at the liquefaction interface and, dueto the pulling force being applied, displaced and pressed into thetissue. This may be continued until the entire augmentation element isconsumed, or until the operator stops the process. Thereafter, thearrangement is retracted towards the proximal side.

Optionally, the foot may include radially protruding blades that dividethe augmented regions into segments, as taught in WO 2010/045 751.

Optionally, the augmentation element may be formed in accordance withcondition a. of the first aspect, and/or at least one of conditionsb.-d. may be fulfilled. Also, at least one of the conditions A.-E. ofthe fourth aspects may be fulfilled.

In accordance with the first as well as with the second, third, fourthor fifth aspect of the invention, also a kit of parts/an assembly forcarrying out the respective method is provided. The kits of partsinclude the tool, the augmentation element and (if used for the method)the auxiliary element, these items having properties describedhereinbefore and hereinafter referring to the respective methods.

An assembly according to the fifth aspect includes in addition to atool, an auxiliary element and an augmentation element at leastpartially encompassing the tool or the auxiliary element also the devicefor deflecting mechanical oscillations (this includes the possibilitythat the tool itself serves as the oscillation deflector).

In accordance with a sixth aspect of the invention, an initial openingis made by a set-up in which a vibrating tool (sonotrode) or a counterelement is also used as hole forming instrument. In accordance with thisaspect, the method comprises

-   -   providing an instrument, the instrument including a distal and        with a piercing tip and/or a cutting edge;    -   providing a thermoplastic augmentation element;    -   placing the instrument with the distal end in contact with the        hard tissue and/or hard tissue replacement material and pressing        the instrument against the hard tissue and/or hard tissue        replacement material to force the instrument into the hard        tissue and/or hard tissue replacement material;    -   placing the augmentation element in contact with a face of the        instrument, the face facing to the proximal side,    -   pulling the instrument towards a proximal direction against the        augmentation element while energy is coupled into the        augmentation element;    -   thereby liquefying material of the augmentation element to yield        liquefied material;    -   causing portions of the liquefied material to penetrate into        structures of the hard tissue and/or hard tissue replacement        material;    -   allowing the liquefied material to harden and to thereby become        augmentation material; and    -   removing the instrument.

During the forcing step, mechanical energy may be coupled into theinstrument. Especially, the instrument may be a vibration tool by whichin the step of pulling the energy is coupled into the augmentationelement in the form of mechanical vibration energy. Then, the vibrationsource generating such vibrations may firstly generate mechanicalvibrations for reaming tissue (to be precise: hard tissue and/or hardtissue replacement material) in a forward movement of the tool and thenfor liquefying portions of the augmentation element in a backwardmovement of the tool.

The invention according to its sixth aspect also concerns an accordingassembly.

It is readily possible to combine features and embodiments of thedifferent aspects with each other. Especially, embodiments of the forthaspect are advantageously provided with features/conditions thatcharacterize the first, second and third aspects and vice versa. Thefirst aspect also combines well with the second aspects, and inembodiments the method according to the third aspect may be applied inaddition to (and subsequently to) the first and/or second aspect.

All of aspects 1-4 can be combined with the fifth aspect, and all ofaspects 1-5 (with the possible exception of embodiments of the fifthaspect where the tool includes a cable for deflecting the oscillations)can be combined with the sixth aspect.

For all embodiments of aspects 1,-2, 4, 5 and 6 of the invention, theaugmentation step may be followed by a subsequent step of inserting theimplant.

The implant may, in accordance with a first option, for examplebe/include a screw that has an outer thread. The thread may beself-cutting, or previously a thread cutter may be used. The threadengages with corresponding structures in the augmented hard tissue/hardtissue replacement material.

In accordance with a second option, mechanical vibration energy or heatmay be used to anchor the joining element in the augmented opening. Tothis end, in accordance with a first possibility, the joining elementmay include thermoplastic material weldable to the augmentationmaterial. In accordance with a second possibility, the joining elementmay include a material that is not liquefiable by being brought to atemperature at which the augmentation material is liquid, and structurewith pores, openings or the like capable of making a positive-fitconnection with the augmentation material. The first and secondpossibilities can be combined with each other. Also, it is possible tocombine the first and second option, for example by using a metallicscrew with a porous surface as a joining element, whereby thethermoplastic lining and/or lining element may penetrate into the poreswhen the screw is inserted in a heated state, so that after cooling thescrew is fixed by a positive-fit connection. Techniques of joining afirst (base) part and a second (based) part with each other in thismanner are disclosed in WO 2008/034 276 incorporated herein by referencein its entirety.

Mechanical vibration or oscillation suitable for devices and methodsaccording to embodiments of the invention that include liquefaction of apolymer by friction heat created through the mechanical vibration haspreferably a frequency between 2 and 200 kHz (even more preferablybetween 10 and 100 kHz, or between 20 and 40 kHz) and a vibration energyof 0.2 to 20 W per square millimeter of active surface. The vibratingelement (tool, for example sonotrode) is, for example, designed suchthat its contact face oscillates predominantly in the direction of theelement axis (longitudinal vibration) and with an amplitude of between 1and 100 μm, preferably around 10 to 30 μm. Rotational or radialoscillation is possible also.

For specific embodiments of devices, it is possible also to use, insteadof mechanical vibration, a rotational movement for creating the namedfriction heat needed for the liquefaction of the anchoring material.Such rotational movement has preferably a speed in the range of 10,000to 100,00 rpm.

A further way for producing the thermal energy for the desiredliquefaction (for the augmentation process and possibly also foranchoring the joining element) includes coupling electromagneticradiation into the augmentation element and/or into an element in avicinity thereof in direct or indirect heat conducting contact with theaugmentation element. Especially, a light conductor may be used for thispurpose. The light conductor may, for example, be a tube-shapedtransparent light conducting tool, for example a hollow cylinder ofglass or another (for example, plastic) material that is transparent andhas a sufficiently high index of refraction for the used radiation (forexample, visible or infrared laser radiation).

In this, absorption preferably takes place within the augmentationmaterial to be liquefied or in the immediate vicinity thereof. Dependingon the requirements and the set-up the radiation therein may be absorbedat different places:

-   -   a. in accordance with a first variant, the distal end of the        tool may be provided with an absorbing coating or surface so        that the distal end of the tool—that interfaces with the        augmentation element—is heated, so that the generated heat        causes the augmentation element to be liquefied at the interface        to the tool.    -   b. in accordance with a second variant, the augmentation element        is so as to at least partially absorb the radiation. If the        augmentation element strongly absorbs the radiation (for example        by having a high concentration of a pigment or other absorber or        in that the polymer itself absorbs the radiation), absorption        will primarily take place at the interface to the tool. In case        of weaker absorption (if, for example, the augmentation element        has a polymer composition that is transparent for the radiation        and a low concentration of absorbing pigments), then absorption        will be distributed through at least a part of the length of the        augmentation element. Then the tendency will be that after the        radiation sets in some time passes until liquefaction starts,        but then a substantial portion of the material will be softened        already. For special applications, it is possible to have a        pre-determined distribution of absorbing pigment in the        augmentation element.    -    Instead of a pigment or an absorbing polymer or in addition        thereto, absorption can be caused by at least one of surface        roughness, micro- or nanosized fillers, or admixed components        with absorbing capability etc.)    -   c. In accordance with a third variant, the augmentation element        is also transparent, and the counter element includes an        absorbing surface, so that the radiation is primarily absorbed        at the interface between the counter element and the        augmentation element. In this variant, the step of coupling        energy into the augmentation element and simultaneously applying        a force often includes advancing the counter element towards the        proximal direction while the tool may for example be held still.

Instead of providing the tool in the form of a radiation conductor, orin addition thereto, it is also possible to include a miniature laser(such as a laser diode or an arrangement of laser diodes) directly inthe tool.

As an even further alternative to providing the tool in the form of aradiation guiding cylinder, the tool may include any other radiationdirecting arrangement. This includes the possibility of directing theradiation to a distal foot and causing it to impinge on the augmentationelement from the distal side in a “rearward” configuration. For thepurpose of radiation directing, the tool may include appropriate meanslike integrated fiber radiation conductors, mirroring faces, etc.

Preferably, electromagnetic radiation in the visible or infraredfrequency range is used, wherein the preferred radiation source is acorresponding laser.

In specific embodiments that include radiation as energy source,parameters and material combinations may be applied as taught inpublications teaching techniques of implanting implants that includeheat deformable materials and that teach heating these materials byradiation; or publications that teach heating a thermoplastic materialfor other purposes. Such publications include, for example, US2012/0157977, US 2011/0160870, US 2012/0328360, WO 2012/141813, US2012/129131 (including a listing of lasers and teachings of absorptionand chromophores/pigments as well as considerations of laser operatingconditions and energy considerations including thermal regulation), allincorporated herein by reference.

According to an even further alternative, the energy may be supplied tothe system by way of electric heating of one of the device parts.

-   -   a. According to a first possibility, the tool may include a        resistance heater in immediate vicinity to the augmentation        element, for example directly at the interface. (or, the        resistance heater itself may be at some distance to the        interface, and the tool includes a heat conductor from the        resistance heater to the interface).    -   b. In accordance with a second possibility, the tool may include        an electrode at the interface to the augmentation element, the        augmentation element is a poor electrical conductor, and some        other element—for example, the auxiliary/counter element or, if        available, a protective sheath element or other—includes a        further electrode so that electricity is conducted through the        augmentation element and thereby heats the latter. The        arrangement of the electrodes in this may influence the location        of primary heating. In embodiments, teachings of prior art        documents such as US 2010/0241229 relating to resistance heating        of electrically conductive polymers and especially the teaching        relating to materials and heating operating parameters, may be        referred to; US 2010/0241229 being incorporated herein by        reference.

In this text the expression “thermoplastic material being liquefiablee.g. by mechanical vibration” or in short “liquefiable thermoplasticmaterial” or “liquefiable material” is used for describing a materialincluding at least one thermoplastic component, which material becomesliquid or flowable when heated, in particular when heated throughfriction i.e. when arranged at one of a pair of surfaces (contact faces)being in contact with each other and vibrationally or rotationally movedrelative to each other, wherein the frequency of the vibration isbetween 2 kHz and 200 kHz, preferably 20 to 40 kHz and the amplitudebetween 1 μm and 100 μm, preferably around 10 to 30 μm. Such vibrationsare, for example, produced by ultrasonic devices as is known for dentalapplications. For being able to constitute a load-bearing connection tothe tissue, the material has an elasticity coefficient of more than 0.5GPa, preferably more than 1 GPa. (The material property values mentionedin this text generally refer to room temperature (23° C.) unlessreferring to temperatures or defined otherwise in this text). Theelasticity coefficient of at least 0.5 GPa also ensures that theliquefiable material is capable of transmitting the ultrasonicoscillation with such little damping that inner liquefaction and thusdestabilization of the liquefiable element does not occur, i.e.liquefaction occurs only where the liquefiable material is at theliquefaction interface to the stop face. The plastification temperatureis preferably of up to 200° C., between 200° C. and 300° C. or even morethan 300° C. Depending on the application, the liquefiable thermoplasticmaterial may or may not be resorbable.

However, in applications where only minimal bearing capacity is required(i.e. applications for which the required capability of transferringstress is below 5 MPa or below 1 MPa), the thermoplastic material mayalso be substantially softer. Especially, due to the liquefaction takingplace directly at the interface between the tool and the augmentationelement, no mechanical energy has to be transmitted through the elementitself. Thus, during the process and thereafter (thus also generally atthe temperature at which it is used, for example room temperature) itmay be comparably soft, even to the point of being waxy. In other words,the advantages of an elasticity coefficient of at least 0.5 GPa do notapply or are at least not pronounced in these systems. Since theintegration of drugs or other biologically active substances oftenrequires very low temperatures, this technique allows the use polymersas drug carriers that have a glass temperature much below 0° C. or even−20° C. or having a very low molecular weight to minimize the energyinput to induce melting or polymers with a melting point only slightlyabove body temperatures, e.g. above 40° C. or 50° C. but below 80° C.

For applications with no or reduced load bearing capacity requirements(for example, below 5 Mpa) even elastomer materials for the augmentationmaterials may be used, these materials having, for certain applications,advantages in terms of ideal stress distribution, for example in poor,osteopenic bone.

Suitable resorbable polymers are, for example, based on lactic acidand/or glycolic acid (PLA, PLLA, PGA, PLGA etc.) orpolyhydroxyalkanoates (PHA), polycaprolactones (PCL), polysaccharides,polydioxanones (PD), polyanhydrides, polypeptides or correspondingcopolymers or blended polymers or composite materials containing thementioned polymers as components are suitable as resorbable liquefiablematerials. Thermoplastics such as, for example, polyolefins,polyacrylates, polymetacrylates, polycarbonates, polyamides, polyesters,polyurethanes, polysulphones, polyaryl ketones, polyimides, polyphenylsulphides or liquid crystal polymers (LCPS), polyacetals, halogenatedpolymers, in particular halogenated polyoelefins, polyphenylenesulphides, polysulphones, polyethers, polypropylene (PP), orcorresponding copolymers or blended polymers or composite materialscontaining the mentioned polymers as components are suitable asnon-resorbable polymers. Examples of suited thermoplastic materialinclude any one of the polylactide products LR708 (amorphous Poly-L-DLlactide 70/30), L209 or L210S by Bohringer Ingelheim.

Specific embodiments of degradable materials are Polylactides like LR706PLDLLA 70/30, 8208 PLDLA 50/50, L210S, and PLLA 100% L, all ofBohringer. A list of suitable degradable polymer materials can also befound in: Erich Wintermantel und Suk-Woo Haa, “Medizinaltechnik mitbiokompatiblen Materialien und Verfahren”, 3. Auflage, Springer, Berlin2002 (in the following referred to as “Wintermantel”), page 200; forinformation on PGA and PLA see pages 202 ff., on PCL see page 207, onPHB/PHV copolymers page 206; on polydioxanone PDS page 209. Discussionof a further bioresorbable material can for example be found in C ABailey et al., J Hand Surg [Br] 2006 April; 31(2):208-12.

Specific embodiments of non-degradable materials are: Polyetherketone(PEEK Optima, Grades 450 and 150, Invibio Ltd), Polyetherimide,Polyamide 12, Polyamide 11, Polyamide 6, Polyamide 66, Polycarbonate,Polymethylmethacrylate, Polyoxymethylene, or polycarbonateurethane (inparticular Bionate® by DSM, especially Bionate 75D and Bionate 65D;according information is available on datasheets publicly accessible forexample via www.matweb.com by Automation Creations, Inc.). An overviewtable of polymers and applications is listed in Wintermantel, page 150;specific examples can be found in Wintermantel page 161 ff. (PE,Hostalen Gur 812, Höchst AG), pages 164 ff. (PET) 169ff. (PA, namely PA6 and PA 66), 171 ff. (PTFE), 173 ff. (PMMA), 180 (PUR, see table), 186ff. (PEEK), 189 ff. (PSU), 191 ff. (POM—Polyacetal, tradenames Delrin,Tenac, has also been used in endoprostheses by Protec). The liquefiablematerial having thermoplastic properties may contain foreign phases orcompounds serving further functions. In particular, the thermoplasticmaterial may be strengthened by admixed fillers, for example particulatefillers that may have a therapeutic or other desired effect. Thethermoplastic material may also contain components which expand ordissolve (create pores) in situ (e.g. polyesters, polysaccharides,hydrogels, sodium phosphates) or compounds to be released in situ andhaving a therapeutic effect, such as promotion of healing andregeneration (for example, growth factors, antibiotics, inflammationinhibitors or buffers such as sodium phosphate or calcium carbonateagainst adverse effects of acidic decomposition). If the thermoplasticmaterial is resorbable, release of such compounds is delayed.

If the liquefiable material is to be liquefied not with the aid ofvibrational energy but with the aid of electromagnetic radiation, it maylocally contain compounds (particlulate or molecular) that are capableof absorbing such radiation of a specific frequency range (in particularof the visible or infrared frequency range), e.g. calcium phosphates,calcium carbonates, sodium phosphates, titanium oxide, mica, saturatedfatty acids, polysaccharides, glucose or mixtures thereof.

Fillers used may include degradable, osseostimulative fillers to be usedin degradable polymers, including: β-Tricalciumphosphate (TCP),Hydroxyapatite (HA, <90% crystallinity; or mixtures of TCP, HA, DHCP,Bioglasses (see Wintermantel). Osseo-integration stimulating fillersthat are only partially or hardly degradable, for non degradablepolymers include: Bioglasses, Hydroxyapatite (>90% cristallinity),HAPEX®, see S M Rea et al., J Mater Sci Mater Med. 2004 September;15(9):997-1005; for hydroxyapatite see also L. Fang et al., Biomaterials2006 July; 27(20):3701-7, M. Huang et al., J Mater Sci Mater Med 2003July; 14(7):655-60, and W. Bonfield and E. Tanner, Materials World 1997January; 5 no. 1:18-20. Embodiments of bioactive fillers and theirdiscussion can, for example, be found in X. Huang and X. Miao, JBiomater App. 2007 April; 21(4):351-74), J A Juhasz et al. Biomaterials,2004 March; 25(6):949-55. Particulate filler types include: coarse type:5-20 μm (contents, preferentially 10-25% by volume), sub-micron(nanofillers as from precipitation, preferentially plate like aspectratio >10, 10-50 nm, contents 0.5 to 5% by volume).

A specific example of a material with which experiments were performedwas PLDLA 70/30 including 30% (weight percent) biphase Ca phosphate thatshowed a particularly advantageous liquefaction behaviour.

Material compositions and mixtures, for example compositions includingCa phosphate, may also be provided with—for exampleencapsulated—pharmaceutical substances for being released targetedlyinto the surrounding tissue. Such pharmaceutical substances may includegrowth promoting, antibiotic, anti-inflammatory and/or otherwise healingand/or preventing agents.

The material of the tool (for example, sonotrode) and/or the material ofthe auxiliary element may be any material that does not melt at themelting temperatures of the liquefiable material. Especially, the tooland/or the auxiliary element may be of a metal, for example a titaniumalloy. A preferred material is titanium grade5. This material, inaddition to being generally suited for implantable devices, has acomparably low heat conduction. Because of this low heat conduction, themelting zone arising in liquefiable material and at the interface to thedirecting structure is heated quickly, without the surroundings beingheated to too high temperatures. Alternative materials for the tooland/or the auxiliary element are other metals like other titaniumalloys, stainless steel, ceramics like Zirconium oxides or Aluminumoxides, or hard plastics such as PEEK etc.

The effect of low heat conduction away from the augmentation materialmay, as an alternative to using a material with low heat conduction forthe tool, also be achieved by a coating of a low heat conductionmaterial on a tool of an arbitrarily chosen material (metal), includingsteel or aluminum.

BRIEF DESCRIPTION OF THE DRAWINGS

In the following, ways to carry out the invention and embodiments aredescribed referring to drawings. The drawings mostly are schematic. Inthe drawings, same reference numerals refer to same or analogouselements. The drawings show:

FIG. 1 bone tissue with an initial opening;

FIGS. 1a and 1b distal portions of opening forming sonotrodes;

FIG. 2a -8 arrangements including a tool (namely, a sonotrode), anaugmentation element and/or an auxiliary element for segmentedaugmentation;

FIGS. 9a -20 concepts of augmentation with impact/energy minimization;

FIGS. 21-25 concepts of deflecting mechanical vibrations for anaugmentation process;

FIG. 26 the concept of using radiation for coupling energy into theaugmentation element; and

FIG. 27 the concept of using electricity for coupling energy into theaugmentation element.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

FIG. 1 shows a portion of bone tissue of a living human or animal bone.For example, the bone tissue may be jawbone tissue or bone tissue ofother regions of the skull or may be bone tissue of the spinal column,such as of a vertebral body, or may be bone tissue of an extremity, orof a bone of the thorax, or of any other part of the human or animalbone framework. The depicted bone tissue includes comparably densecortical bone 201 along the bone surface and less dense trabecular orspongy bone 202. An initial opening 203 in which an implant—such as, forexample, a bone screw or a suture anchor—is to be anchored has, forexample, been made by drilling. Alternatively, the initial opening 203may be naturally present or may have been caused otherwise, for examplein the course of a surgical operation. An opening axis 204 is shown. Incase the opening is made by drilling, the opening may have rotationalsymmetry with respect to the axis 204. Because of the relatively lowmechanical load resistance of the trabecular bone, especially if thebone is osteoporotic or osteopenic, it is desirable to augment themechanical stability of the bone tissue prior to the implantation of theimplant. According approaches have been described in WO 2010/045 751incorporated herein by reference.

In accordance with a further, sixth, aspect of the invention, an initialopening 203 is made by a set-up in which a vibrating tool (sonotrode) ora counter element is also used as hole forming instrument.

Referring to FIGS. 1a and 1b , firstly the option of using the tool (forexample, sonotrode) as hole forming element is discussed. For thepurpose of forming the initial opening 203, the forward (distally)facing portions of the sonotrode are accordingly shaped. Duringintroduction of the tool, the tool is forced into a distal directionwhile vibrations are coupled into the tool, wherein the parameters ofthe vibration are chosen to cause the distal end of the sonotrode to beforced into the bone tissue to cause an opening that is cylindrical orthat in cross section is ring-shaped. This may be combined with asubsequent augmentation step in a ‘rearward’ configuration as, forexample, described in WO 2010/045751 incorporated herein by reference,or as described for some embodiments hereinafter. More specifically,after the forcing step is finished, the sonotrode is again subject tomechanical oscillations—with accordingly adapted energy and otherparameters—while it is retracted. At this time, proximally of the mostdistal sonotrode portion an augmentation element is placed and is atleast in part liquefied by the simultaneous retraction and vibrationenergy impact.

FIGS. 1a and 1b show example of distal portions of a sonotrode 3. Thedistal portions include a distal broadening that forms a shoulder thatis pressed against the augmentation element 1 in the augmentation stepin which the sonotrode is subject to a pulling force, and the interfacebetween the sonotrode (or, More particularly, the shoulder) and theaugmentation element serves as the liquefaction interface. The distallyfacing portions of the sonotrode are equipped with a cutting edge 93(FIG. 1a ) and/or with a piercing tip 94 (FIG. 1b ) configurations witha piercing tip 94 are especially suited in situations where the bonetissue is very weak and has little density and/or the diameter of theopening is comparably small.

In accordance with a second option, the instrument by which the initialopening is made or extended is not the tool that is later used forcoupling the energy required for liquefaction into the augmentationelement, but is the counter element for applying the counter force (in aforward configuration where the tool is held towards a distal directionwhile energy is coupled into the augmentation element for liquefyingmaterial of it). The counter element 2 in this may be shaped for examplelike the shown in FIG. 1a , FIG. 1b and described hereinbefore referringto the tool.

Alternatively, the step of forcing the counter element into the tissuemay be carried out manually without any further energy source.

In embodiments according to the second option, the energy coupled intothe augmentation element may as an alternative to mechanical energy alsobe radiation and/or heat.

For the forcing step and for the augmentation step, the vibration toolis coupled to a vibration source, in particular to a source ofultrasonic vibration (e.g., piezoelectric vibration generator possiblyincluding a booster to which the tool is coupled) and the tool and issuitable for transmission of the vibration from the proximal tool end tothe distal tool and, preferably such that a tool face—that faces to theproximal side and in contact with the augmentation element forms theliquefaction interface—vibrates with a maximal longitudinal amplitude.It is possible also to activate the tool to vibrate in a radial or in arotational direction.

For the augmentation step, it is preferable to work with a substantiallyconstant output of vibrational power, i.e. with vibration (basevibration) of substantially constant frequency and amplitude, whereinthe frequency is in the above named frequency range (preferably between2 and 200 kHz, between 10 and 100 kHz, or between 20 and 40 kHz) and isa resonant frequency of the vibrating system, and wherein the amplitudeis in the range of 10 to 50 μm, preferably 20-40 μm. For the forcingstep, in particular in cases in which the hard tissue constitutes arelatively high resistance, vibrational modes as known from, forexample, vibration assisted bone cutting are preferable. Such vibrationmodes usually include pulses of higher amplitude and possibly sharperprofiles (e.g., rectangular profile or Dirac impulse) and are, forexample, provided by modulating the amplitude of the base vibration to,for example, form pulses of higher amplitude and preferably by alsosharpening the input wave form as compared with the base vibration andby matching the system's resonance frequency. The so created pulses caninclude one or several wave cycles of the base vibration each, and canbe periodic with a modulation frequency preferably in the range of 0.5-5kHz or they can be generated stochastically (in amplitude and modulationfrequency) but in any case in phase with the system's resonancefrequency. A means for producing stochastically occurring pulses isdescribed in the publication U.S. Pat. No. 7,172,420, which isincorporated herein by reference. Therein the higher amplitude of thepulses is preferably greater than the base vibration amplitude by afactor of between 2 and 10.

Alternatively, such pulses can be achieved by overlaying the basevibration or replacing it with a pulse excitation generated by amechanical impulse generator (e.g., including a rotationally drivenunbalanced mass or hammer). Therein the higher amplitude of the pulsesis preferably again greater than the base vibration amplitude by afactor of between 2 and 10 and the pulse frequency which may be regularin the region of 20 to 200 Hz and in particular lower than the lowestresonance frequency of the vibrating system (e.g., undesired flexuralvibration of the sonotrode). The low pulse frequencies are particularlyimportant if material liquefaction during the forcing step is possiblebut is to be prevented as best as possible.

If as described above two different vibration modes are to be used inthe forcing and in the anchoring step, the vibration source to which thevibration tool is coupled during the two steps is to be equipped forselectively producing the two vibration modes and with switching meansfor switching the vibration source from one vibration mode into theother one.

Referring to the following figures, methods of augmenting bone tissueof, for example, a configuration as shown in FIG. 1 are described. Withreference to FIGS. 2-8, embodiments of segmented augmentation aredescribed.

A first example of an assembly for circumferential segmentation isdepicted, in sections along different planes, in FIGS. 2a and 2b . FIG.2c shows a view of the sonotrode 3 of the assembly, FIG. 2d shows aschematic view of the assembly in section in the initial opening duringthe process, FIG. 2e shows a variant of an augmentation element, FIG. 2fshows the augmentation element of FIG. 2e together with a speciallyadapted auxiliary element, and FIG. 2g shows yet another augmentationelement. FIG. 2a shows a cross section in plane A-A of FIG. 2 b.

The assembly includes an augmentation element 1 that has two separateaugmentation element portions 1.1, 1.2, a tool (sonotrode) 3, and anauxiliary element 2 serving as counter element. The auxiliary elementforms a guiding shaft 5 and a distal broadening 6 that forms a shoulderso that the augmentation element is capable of being compressed betweenthe sonotrode 3 and the shoulder 6 during the process. The guiding shaftin the depicted embodiment in other word forms part of a counter elementthat in addition to the guiding element shaft includes a distalbroadening 6 with proximally (rearwardly) facing counter element contactfaces through which a counter force is coupled into the augmentationelement portions. The counter force is a force of equal magnitude butopposite direction to the force by which the sonotrode is pressedagainst the augmentation element portions.

The guiding shaft 5 does not have the shape of a rotational cylinder butis circumferentially structured to include two axial grooves in whichthe two augmentation element portions 1.1, 1.2 are placed. The sonotrode3 is correspondingly segmented to include two pushing portions 3.1, 3.2with a cross section approximately corresponding to the cross section ofthe augmentation element portions 1.1, 1.2. The sonotrode also includesa central cannulation 3.7 for the shaft portion 5 of the auxiliaryelement 2.

In alternative embodiments, the auxiliary element may lack the distalbroadening and merely be a guiding pin. In these embodiments, thecounter force opposite to the sonotrode pressing force may be exerted bythe tissue against which the augmentation element is pressed, or anadhesion and/or friction force by which the augmentation elementportions adhere to the guiding element, or a combination thereof. Inaddition or as an alternative, it is also possible to provide the shaftand the augmentation element with surface structure engaging with eachother, such as small indentations of the shaft into which correspondinginner protrusions of the augmentation element protrude.

The segmentation of the augmentation element as illustrated with respectto FIGS. 2a and 2b may be over the full axial length of the augmentationelement portions, or it may be partial, i.e., the segmentation my berestricted to certain axial positions whereas in other axial positionsthe augmentation element may include a portion 1.8 that surrounds theguiding shaft, so that the augmentation element is one-piece. A firstaccording example is shown in FIG. 2e , where the shaft surroundingportion 1.8 is at the proximal end of the augmentation element. By theconstruction of the augmentation element shown in FIG. 2e , towards thedistal end of the augmentation element there are open gaps between theelement portions 1.1, 1.2. This may optionally be combined with anauxiliary element having a distal end that has according projections 5.2as illustrated in FIG. 2f that prevent liquefied portions of thethermoplastic material to be spread into circumferential directions and.More particularly, the dimensions of the open gaps and the projections5.2 may be adapted to each other so that the distance d₁ is smaller thanor approximately equal to the distance d₂.

Yet another embodiment of an augmentation element with portions 1.1-1.5held together by a shaft surrounding portion 1.8 is shown in FIG. 2g .In this embodiment, the shaft surrounding portion is in an axiallycentral position. Also the embodiment of FIG. 2g may optionally be usedtogether with an auxiliary element of the kind depicted in FIG. 2 f.

In FIG. 2b a proximodistal axis 4 is also depicted. In the configurationof FIGS. 2a-2g , the elements 1, 2, 3, of the assembly do not havecircular symmetry around this axis.

For carrying out the method with segmented augmentation, the assembly ofFIGS. 2a and 2b is placed in the initial opening with the axis 4approximately parallel to the opening axis 204. Then the sonotrode 3 ispressed towards the distal side while mechanical oscillations arecoupled into the tool and while the auxiliary element is held againstthe pressing force so that the augmentation element is compressedbetween the vibrating sonotrode and the auxiliary element. The vibrationenergy is chosen to be sufficient so that a melting process of thethermoplastic auxiliary element material sets in the forward movement ofthe sonotrode (and/or the rearward movement of the auxiliary element)causes the molten thermoplastic material to be pushed aside and intostructures of the surrounding cancellous bone tissue. This isillustrated in FIG. 2d . The displaced thermoplastic material portions11.1, 11.2 re-solidify and thereby augment the bone tissue. The processis, for example, continued until all augmentation element material hasbeen liquefied and displaced and until the distal end faces of thepushing portions abut against the shoulder 6 formed by the distalbroadening.

Because the augmentation element is segmented, i.e. includes twoaugmentation element portions at different angular positions withrespect to the proximodistal axis, the thermoplastic material portions11.1 remain separate and form two augmentation regions.

Whereas referring to FIGS. 2a-2d circumferential segmentation of theaugmentation element has been described referring to a configuration toaugment a circular hole and using two segmentation element portions in asymmetrical arrangement, various other embodiments are possible. Forexample, the two segmentation element portions need not be arrangedsymmetrically with respect to a symmetry plane as the illustratedembodiment, but other, asymmetrical arrangements are possible. Further,more than two segmentation element portions may be used (as, forexample, in the lower part of the augmentation element of FIG. 2g ), forexample three, four, five, six or even more—all in a symmetrical orasymmetrical arrangement. Also, the augmented initial opening need notbe circular but can have any other shape.

A further example of segmented augmentation is described referring toFIGS. 3a -4. This example uses the insight that the augmentation processdoes not rely on circular symmetry of the opening to be augmented.Rather, it is possible for mechanical energy capable of liquefying thethermoplastic augmentation element also in non-circular arrangements.

FIG. 3a shows, in cross section along plane A-A in FIG. 3d , a guidingshaft 5 of an auxiliary element, and an augmentation element 1surrounding the guiding shaft 5. The guiding shaft and the augmentationelement have a translational symmetry along the proximodistal axis and agenerally triangular shape in cross section. The sonotrode 3 is proximalof the augmentation element and has a portion with a similar shape.

For augmentation, in a first step, the assembly of FIGS. 3a and 3d isplaced in the initial opening. Then the sonotrode 3 is pressed towardsthe distal side while mechanical oscillations are coupled into the tooland while the auxiliary element is held against the pressing force sothat the augmentation element is compressed between the vibratingsonotrode and the auxiliary element and so that at the interface betweenthe sonotrode and the augmentation element the thermoplastic material ofthe augmentation element starts melting and is displaced into thesurrounding bone tissue. The result is illustrated, again in section, inFIG. 3b . The initial opening, that is triangular in cross section, issurrounded by an augmented region where the bone tissue isinterpenetrated by the augmentation material 11. The dashed line 21 inFIG. 3b shows where in a next step a bore is added. The bore 23 has acircular cross section and is thus suitable for implanting, in asubsequent step (not shown) a surgical screw. When the bore is made,further bone tissue as well as regions of the augmentation material areremoved. What remains (FIG. 3c ) is bone tissue that is augmented in theregions where the augmentation material is not removed. FIG. 3cillustrated three separated augmentation material portions 11.1, 11.2,11.3. The lobes 25 that may optionally remain at the edges of theinitial opening may add further flexibility and may soon afterimplantation of the surgical screw (or other implant) be filled bytissue.

As an alternative to being triangular, the initial opening and theaugmentation element in variants of this group of embodiments may haveother non-circular cross sections. An example of such an alternative isillustrated in FIG. 4, schematically in section perpendicular to theproximodistal axis. The initial opening and the augmentation element 1have a generally elongate cross section, so that after augmentation andadding the bore (dashed line 21) two augmented regions will remain.Various other non-circular shapes are possible, both, symmetric andasymmetric. In particular, it is possible to adapt the shape to theanatomy of the place where the implant is to be anchored.

The approach of FIG. 4 can be implemented both, in forwardconfigurations with a sonotrode 3 that is pushed during the augmentationprocess (as illustrated in FIG. 3d ) and in “rearward” configurations inwhich the sonotrode is pulled, as for example described in WO 2010/045751. In “rearward” configurations, further in accordance with the sixthaspect, the sonotrode may optionally have a cutting distal edge thatallows manufacturing the initial opening by introduction of thesonotrode while mechanical energy is coupled into the sonotrode.

With reference to FIGS. 5a and 5b yet another possibility to providesegmented augmentation is depicted. FIG. 5a shows a section along theproximodistal axis, whereas FIG. 5b shows a view onto the tissuesurface. In accordance with this possibility, the sequence of steps isreversed. As a further difference to the previously describedembodiments, an auxiliary element with a guiding shaft is not required.Instead, a plurality of pin-like augmentation elements 31 are implantedin a first step. To this end, an according number of bores (initialopenings) may be prepared, whereafter the pin-like augmentation elements31, which consist of the thermoplastic material, are implanted. Thepre-made bores may as an option have a depth that merely corresponds tothe depth of the cortical bone tissue, i.e., the preparation then onlyincludes locally removing the cortical bone. Alternatively, the pre-madebores may have a larger depth, or in case of weak bone oralready-removed cortical bone, the augmentation elements may be directlydriven into the bone tissue without any prior additional removal of bonetissue. Concerning the process of driving implants (here serving asaugmentation elements) of thermoplastic material into bone tissue, it isreferred to WO 02/06981 the content of which is incorporated herein byreference in its entirety.

The augmentation elements are implanted along the contour 32 of a bore33 that is made subsequently to implanting the augmentation elements.The bore may be conical or have another shape with a cross section thatdiminishes as a function of the dept. More particularly, the crosssection at the bone surface is such that the augmentation element iswithin the bore (dashed line 32 in FIG. 5b ), and the cross section atthe distal end of the bore (dotted line 34 in FIG. 5b ) is such that atleast part of the augmentation elements is outside of the bore. By this,not only a circumferential segmentation may be achieved but also arestriction of the augmented region to the deeper part of the bore sothat for example no augmentation material reaches the top. This may bedesired to make possible that after healing the cortical bone can becontiguous around the implant.

FIGS. 5c and 5d yet depict two versions of a guiding tool 121 forpreparing bores for the augmentation process of FIGS. 5a and 5b . Thetool 121 has a body 122 that in the depicted embodiments is essentiallydisk-like. The body has per augmentation element a guiding opening 123for guiding a drill that pre-makes the holes and/or that guides thepin-like augmentation elements and sonotrode during the insertion of theaugmentation elements. The tool may further include a holding structure124 such as one or more spikes that secures the tool 121 against lateralmovements. The embodiment of FIG. 5d further includes a central throughopening 125 for the drilling of a centering bore for the later conicalbore.

Whereas this embodiment has been described with a conical bore or a borethat has an otherwise tapering shape, the concept of implanting anaugmentation element or a plurality of augmentation elements along acontour of a bore made subsequently may also be applied to cylindricalbores. In these embodiments, the outer contour of the bore should gothrough the implanted augmentation elements.

It is further also possible to combine a cylindrical bore with pin-likeaugmentation elements that are not implanted parallel to theproximodistal axis but radially outward (so that the distal end pointsaway from the proximodistal axis). By such configuration, a similareffect as the one of the depicted embodiment may be achieved.

In the shown embodiment, two pin-like augmentation elements 31 areshown, however, the concept may also be realized with one or with morethan two augmentation elements. Generally, a plurality of augmentationelements may be arranged in a symmetrical or in an asymmetricalconfiguration.

The effect of restricting the augmentation material to deeper regions ofthe bore by means of a tapering bore may also be used in configurationsin which the augmentation material is applied by a method as describedreferring to FIGS. 1-4 or by variants thereof without segmentation (but,for example, with a tube-shaped augmentation element, including‘rearward’ configurations as described in WO 2010/045751 incorporatedherein by reference).

FIG. 6 shows, in cross section along the proximodistal axis, aconfiguration where an initial opening 203 of for example cylindricalshape has been augmented so that augmentation material portions 11strengthen the bone tissue. This augmentation may be a segmentedaugmentation where the segmentation material is confined to certainangles around the circumference—for example as taught referring toprevious figures—or may be a non-segmented augmentation where theaugmentation material is distributed around the periphery. Subsequently,tissue and material may be removed along the dashed line 33 so that theaugmented bone surface becomes restricted to the deeper regions of theopening.

Circumferential segmentation and depth dependence of the augmentationmay be combined. An example is illustrated in FIGS. 7a-7c . The initialopening is stepped and has a large diameter proximal portion and asmaller diameter distal portion so that a shoulder 111 is formed. Theguiding shaft 5 in cross section has a shape as illustrated in FIG. 7c .FIGS. 7a and 7b correspond to cross sections along planes that in thesection only through the guiding shaft (FIG. 7c ) correspond to thelines A-A and B-B, respectively. The augmentation element has firstaugmentation element portions 1.1, 1.2 that are positioned around at theperiphery and that during the method step of liquefying are pressedagainst the shoulder. Second augmentation element portions 1.3, 1.4 arelocated distally in the channels 5.1 of the guiding shaft. Duringliquefaction, they are pressed against the bottom of the initialopening. The shape of the sonotrode 3 is accordingly adapted. As analternative to the depicted configuration, the auxiliary element mayinclude abutment protrusions that axially extend from the guiding shaftproximally of the shoulder 111 and/or a distal broadening of the kindillustrated in FIG. 2b so that the counterforce to the pressing force isnot exerted by the tissue but by the auxiliary element.

FIG. 8 shows yet another example of segmented augmentation, again incross section parallel to the proximodistal axis. The embodiment of FIG.8 may combine axial segmentation (i.e. augmentation at different depths)with circumferential segmentation. In the embodiment of FIG. 8, theinitial opening is tapered, it is for example conical. The auxiliaryelement 2 has an accordingly tapered shape. For the augmentationprocess, it is to be placed in the initial opening, with acircumferential wall and possibly a distal end in contact with bonetissue as shown in FIG. 8. The auxiliary element is a body with openingsaccessible from the proximal side. Between the openings and thecircumferential wall, there are holes. For example, a larger, centralopening 41 includes a plurality of holes 43 distributed regularly orirregularly around the periphery. Smaller, peripheral openings, forexample, each include a lateral hole 43. The peripheral openings 42 maybe distributed regularly or irregularly along the periphery. It wouldalso be possible for the auxiliary element to include a singleperipheral opening only. The augmentation elements 1 may, for example,be pin-shaped, with an outer diameter adapted to the dimension of theopening they are provided for. During the augmentation process,augmentation elements 1 are inserted in the openings and pressed towardsthe distal direction while mechanical energy impinges on the respectiveaugmentation element. Thereby, the augmentation material at the distalend of the augmentation elements is liquefied and pressed out of theholes into the surrounding tissue. The auxiliary element may be removedafter liquefaction of the augmentation material; for example, removalmay be made immediately after the offset of the mechanical energy input(for example the vibrations) so that the augmentation material is stillsoft in vicinity to the auxiliary element. As an alternative, a cuttingelement may be used for removing the auxiliary element; such cuttingelement may for example be a feature (proximally facing cutting edge orsimilar) adjacent to the holes 43 that cuts through the augmentationmaterial portions that are at the interface between the auxiliaryelement 2 and the bone tissue.

In addition or as an alternative to the openings 41, 42, the auxiliaryelement—that may be viewed as guiding tool for individual augmentationelements 1 may have indentations (openings) along the circumferentialsurface. After an augmentation process using such an auxiliary element,thermoplastic augmentation material portions may protrude into theconical opening and thus need not be restricted to the bone tissue. Suchembodiments are especially advantageous in situations where thesubsequent implantation of the implant involves welding thermoplasticmaterial of the implant to the augmentation material or involves animplant with a surface structure into which, when the augmentationmaterial during implantation is again liquefied, again thermoplasticmaterial may penetrate to generate a positive-fit connection. Theprinciple of a positive-fit connection between a thermoplastic part(here: the augmentation element) and a non-liquefiable part havingaccording structures is, for example, described in WO 2008/034 276incorporated herein by reference; especially the basic principle isshown referring to FIGS. 1-7.

Next, embodiments of the aspect of impact/energy minimization aredescribed. In these described embodiments, the energy coupled into theset-up during the process is mechanical vibration energy and the tool isa sonotrode. However, the concept can readily be expanded to otherenergy forms, including other mechanical energy (for example rotation),heat, electromagnetic radiation.

FIGS. 9a and 9b , in cross sections parallel to the proximodistal axis,show a first approach. It has been found that substantial noise and alsopossibly energy losses are caused by the contact between the sonotrode 3and the guiding shaft 5 of the auxiliary element in configurations wherethe sonotrode and possibly also the augmentation element is/are guidedby the guiding shaft. The region where the tool (sonotrode) and theauxiliary element slidingly overlap is also denoted “telescoping region”in the present text.

In FIGS. 9a and 9b , the inner diameter of the sonotrode is larger thanthe outer diameter of the guiding shaft so that a buffer volume 52 isformed around the guiding shaft. The sonotrode includes an inwardprojection 51 at the distal end thereof. The inward projection is, forexample, an inwardly projecting ridge forming a contact surface indirect contact with the guiding shaft. The contact surface fullyencompasses the shaft forming a sealing for liquefied materialpreventing the latter from penetrating into the buffer volume.

In the embodiment of FIG. 9a , the distal end face of the sonotrode thatforms the contact with the augmentation element 1 is essentially flatand radial with respect to the axis, whereas the embodiment of FIG. 9bhas a tapered sonotrode surface that helps to push the liquefiedaugmentation material outward into the surrounding tissue. In allembodiments, the contact face between the sonotrode and the augmentationelement may generally have any shape, including flat, curved, taperedetc.

In the shown embodiment, the inward projection 51 is one-piece with therest of the sonotrode. In alternative embodiments, a separate part—thatcan be viewed as a bushing—may be used. The use of such separate partmay be advantageous, especially since a suitable material may be used.Such suitable material may be chosen so that it minimizes the sonotrodeimpact while it is not necessarily a good conductor for ultrasonicvibrations. An example of a suitable material for a bushing is PEEK;alternatively other polymer materials that have a comparably smallfriction coefficient to steel, such as PTFE, PA, etc. or other plasticor non-plastic materials may be used.

As a further option, the inward projection, especially if formed by aseparate part (bushing), could include a small circumferential scrapinglip in contact with the guiding shaft. As an alternative to such ascraping lip, also a corresponding fit allowing for a relative movement,such as a transition fit etc. may be used, especially for a hard-softmaterial combination between guiding shaft and projection/bushing 51.

In addition or as an alternative to the above-discussed variants, thebuffer volume 52 may be partially or entirely filled by a material withreduced friction/noise development between the shaft and the vibrating(or directly heated or energy conducing) parts. Such material then mayserve as a kind of inner liner; the material may for example be apolymer such as PEEK, PTFE, PA, etc.

FIG. 10 depicts, in cross section perpendicular to the proximodistalaxis, an embodiment where the sonotrode includes inwardly projectingaxial ribs 54 so that again the contact surface between the sonotrodeand the guiding shaft is diminished. This may optionally be combinedwith a distal inwardly projecting ridge as shown in FIGS. 9a, 9b . FIG.11 (in cross section parallel to the proximodistal axis) similarly showsa configuration with inwardly projecting circumferential ribs 55. Again,a combination with the distal ridge is possible. Alternatively, insteadof ribs or in addition thereto the sonotrode may include other inwardprojections such as humps etc.

FIGS. 9a -11, as well as FIGS. 17 and 18 described hereinafter, showexamples of configurations where the area of the surface between thesonotrode and the auxiliary element is considerably reduced compared toconfigurations where the sonotrode is a cylindrical sleeve surrounding acylindrical shaft. More particularly, in the telescoping region thecontact surface is substantially (for example by at least a factor 2)smaller than the outer surface area of the auxiliary element in thattelescoping region.

Another group of approaches for impact minimization, which may becombined with the approach of diminishing the direct contact betweensonotrode and guiding shaft, is shown in FIGS. 12-15. The embodiments ofthese figures all include the concept that the augmentation element isshaped in a manner that causes the augmentation element, or at leastportions thereof, to be liquefied with less energy impact, i.e., onsetas a function of the energy that impinges on the augmentation element isearlier. This allows to reduce the power of the energy source, forexample the power by which the sonotrode is operated.

The cross sections of FIGS. 12 and 13 show a section of a generallyrotationally symmetrical arrangement, with the symmetry axis (not shown)through the guiding shaft 5. The augmentation element 1 of FIG. 12includes outer and inner grooves 61, 62, respectively, whereas theaugmentation element of FIG. 13 has inner grooves 62. The groovessystematically weaken the augmentation element and, by causing necks,provide spots where the liquefaction upon absorption of the mechanicalenergy sets in first. Further, the inner grooves 62 of the embodiment ofFIG. 13 are slanted towards the outside so that after onset ofliquefaction at the necks the more proximal portions slide on the moredistal portions and are forced outwardly, so that additional friction ofnot yet liquefied augmentation material with the lateral walls of theinitial opening and/or an additional pressure onto the liquefiedmaterial is caused, both effects potentially assisting the augmentationprocess. A similar effect could be achieved by outer grooves that runalong same conical surfaces as the illustrated embodiments, i.e. thegrooves are such that after a liquefaction at the weak spots (necks) themore proximal parts of the augmentation element are subject to a shearmovement that forces them outwardly when they are subject to pressurefrom the sonotrode 3. In both variants (and in combinations), anadditional axial division (not shown in FIG. 13) or a circumferentialsegmentation as illustrated in previous embodiments may ensuresufficient flexibility for such an outward movement.

The grooves 61, 62 of the embodiments of FIGS. 12 and 13 or similarweakenings of the augmentation element 1 may also be chosen for notrotationally symmetrical arrangements, such as arrangements that includesegmentation in accordance with any one of the embodiments describedhereinbefore.

The embodiments of FIGS. 14 and 15 show views of other variants ofsystematically weakened augmentation elements. The embodiment of FIG. 14includes an augmentation element 1 having generally a shape of arotational cylinder with a plurality of through holes 63. In thedepicted embodiment, the through holes are arranged in axial rows.Generally, the position and distribution of holes or other weakenings ofthe augmentation element may be chosen according to the needs.

In the embodiment of FIG. 15, the augmentation element 1 havinggenerally a shape of a rotational cylinder includes elongate axial holes64. The axial extension of such holes may be such as to correspond to asubstantial portion (for example, at least ½ or even at least ⅔) of theaxial length of the augmentation element 1. The axial holes, in additionto reducing the power requirements of the mechanical (or other) energyimpact, may have the effect of causing a weak circumferentialsegmentation. The extension (along the circumferential direction) andthe distribution of the axial elongate holes 64 may be chosenaccordingly. In the depicted configuration, the augmentation elementfurther includes bridge portions 65 that form bridges over the elongateholes, for example approximately in their middle, to enhance themechanical stability of the augmentation element. Especially if acircumferential segmentation effect of the augmentation material isdesired, the bridge portions 65 may have a minimal material strengthonly; for example, they may be thinner than the body of the augmentationelement.

The embodiment of FIG. 16 (shown in section) includes a sonotrode 3 withan outwardly protruding (salient) distal feature 71 such as acircumferential ridge. Due to this shape, the sonotrode has a reducedthickness at more proximal positions so that it does not get into directcontact with the bone tissue proximally of the distal feature 71. Thissignificantly reduces the impact, especially frictional heating of theadjacent bone tissue. The same applies if the tool 3 is not a sonotrodebut a heating element or a rotating element.

An outwardly protruding distal feature of the kind illustrated in FIG.16 may be realized in embodiments with a tapering contact face of thesonotrode to the augmentation element (as shown in FIG. 16), inembodiments with a flat contact face, or in combination with any othercontact face shape. Combinations with the approaches of any one of theprevious figures, including minimization of the contact surface betweensonotrode and guiding shaft as illustrated in FIGS. 9-11 are possible.

Another possibility of minimizing the sonotrode impact, especially thenoise created by friction between sonotrode and guiding shaft, is shownin section in FIG. 17. The sonotrode in this embodiment includes aplurality of inwardly facing micro-protrusions 81. Themicro-protrusions, which may be conical or calotte shaped or have othershapes, abut against the auxiliary element 2 guiding shaft and therebycause the contact surface between the sonotrode 3 and the guiding shaftto be minimal. The micro-protrusions 81 have a height that is comparablysmall so that the resulting gap between the shaft and the sonotrode hasa thickness d that is so small that due to surface tension substantiallyno liquefied thermoplastic material will penetrate into the gap. Moreparticularly, the gap thickness d (approximately corresponding to theheight of the protrusions) may be between 0.02 mm and 0.2 mm. In a gaphaving a thickness of this order of magnitude, no thermoplastic materialwill penetrate.

Whereas FIG. 17 shows the micro-protrusions being inwardly protrudingfeatures of the sonotrode, it would also be possible to provideaccording outwardly facing protrusions of the guiding shaft.

As an alternative to micro-protrusions that define punctiform contactsurface portions, it would also be possible to have ridge-shapedmicro-protrusions 82 as illustrated in FIG. 18. The embodiment of FIG.18 includes the micro-protrusions 82 at the guiding shaft; of course,according (inwardly facing) ridge-shaped micro-protrusions may also bepresent at the sonotrode. The radial dimension of the protrusions ofFIG. 18 may again be in the range between 0.02 mm and 0.2 mm.

Next, referring to all embodiments of the various aspects of theinvention, some considerations on augmentation element dimensions,especially wall thickness are made. The thickness primarily depends onthe desired infiltration depth (penetration depth), and on the porosityof the bone. First assuming that the augmentation element is tube-shapedand the radius of the augmentation element is much larger than the wallthickness—so that a plane configuration can be assumed in approximation,for an infiltration depth of 1 mm and a porosity of 40% (healthy bone inthe present model), the wall thickness is 0.4 mm. For a porosity of 80%(osteoporotic bone in the present model), one gets a wall thickness of0.8 mm for a penetration depth of 1 mm, and for a porosity of 60% oneobtains 0.6 mm wall thickness. In the present approximation, the wallthickness is a linear function of the penetration depth, so that forexample for a penetration depth of 2 mm and a porosity of 80%, the wallthickness has to be 1.6 mm. In these considerations, it is assumed thatthe material flow is ideal and that all augmentation element material isdisplaced into the bone tissue. In reality, this is not the case.Rather, the bone tissue promotes a freezing behavior of penetratingthermoplastic material, which freezing behavior is the more pronouncedthe denser the bone tissue. This effect can be taken into account byreplacing the real, measured porosity by a reduced apparent porosity.The apparent porosity can be measured by the following process:

-   -   Augmentation using a simple augmentation cylinder of given wall        thickness d_(w) (for example 0.5 mm) in spongy bone, for example        a pig's femoral condyle, complete displacing in penetration        -   Measuring of an average penetration depth d_(m) and a            penetration height h_(m) (corresponding to the axial            extension of the augmented bone tissue portion)        -   Calculating a correction factor F=d_(m)/d_(t)*h_(s)/h_(m)            where d_(t) denotes the theoretical penetration depth in            accordance with the above considerations for ideal material            flow and h_(s) is the original height of the augmentation            element, and        -   Calculating an apparent porosity P_(A) to be P*F.

In an example measurement with P=35%, the values of d_(m)/d_(t)=0.6 andh_(m)/h_(s)=0.9 have been obtained, so that F=0.667. For a porosity of40% and a penetration depth of 1 mm one then obtains a wall thickness of0.267 mm. The wall thickness is again proportional to both, thepenetration depth and the porosity, so that starting from this valueother wall thicknesses can be calculated.

If not all augmentation material is displaced into the bone tissue,residual wall thicknesses of material remaining within the augmentedopening are to be added to the wall thickness.

In cases of segmented augmentation and/or augmentation elements withopenings, along the axially running edges there will be additionalmaterial flow in circumferential directions to some extent. As a rule,polymer flow will broaden the augmented region (in circumferentialdirection) by about 0.5-1 mm. Thus, at these regions there will be anaccordingly reduced infiltration depth. This is clinically not critical.Especially in dental medicine this will result in a reduced potentialexposure of sensitive structures.

FIG. 19 shows, again in section, yet another approach of sonotrodeimpact minimization. In the embodiment of FIG. 19, the sonotrode 3includes a sonotrode shaft 91 that is, at more proximal axial positions,encompassed by the auxiliary element 2 having the shape a sleeve. Theaugmentation element 1 is held by the sonotrode, for example in aninterlocking connection. For example, the sonotrode 3 may have an outerthread, and the auxiliary element may be screwed onto the sonotrode. Inthe depicted configuration, the sonotrode has an—optional—distalbroadening 92 (foot) that is an additional support securing theaugmentation element against escaping in a distal direction. During theaugmentation process, the sonotrode with the augmentation elementaffixed to it vibrates while the sleeve-like auxiliary element ispressed against the proximal surface of the augmentation element. At theinterface between the sonotrode and the sleeve-like auxiliary element,mechanical energy is absorbed causing the augmentation element materialto partially liquefy. During the process, for example the sonotrode'saxial position may be held still while the auxiliary element 2 ispressed forward.

The embodiment of FIG. 19 features the advantage that due to theconfiguration with the central sonotrode and the peripheral auxiliaryelement, there is only minimal contact between the sonotrode and thetissue surrounding the initial opening.

An assembly corresponding to the one of FIG. 19 would also be possiblein a ‘forward’ arrangement where the contact face between theaugmentation element and the auxiliary element is at the distal end ofthe augmentation element. In such an assembly, the auxiliary element mayfor example have a thin shaft carrying a distal foot (that includes thecontact face), the shaft reaching through the sonotrode. While such aconfiguration is a possibility, the configuration of FIG. 19 has theadditional advantage of being more straightforward to implement.

Further, optionally, the distal end of the sonotrode could be providedwith a cutting or piercing functionality, for example according to thesixth aspect of the invention. Such a piercing or cutting feature couldfor example work as a optionally vibration assisted awl when introducingthe assembly in the tissue—the initial opening does then not need to bepre-made in a separate step but can be made by introducing the assembly.

FIG. 20 shows in section an embodiment including a protecting element96. The protection element at least partially encompasses the sonotrode3 and thereby protects the bone tissue. The protection element 96 mayinclude a distal cutting/reaming structure and/or a tapping structure toprovide the augmented or not augmented bone tissue with a thread.

In the depicted configuration, the protecting element 96 is shown incombination with a stepped opening. This is not a requirement;sufficiently thin (<0.1 mm or 0.05 mm) protecting elements ofsufficiently stiff material (for example steel) may also be usedtogether with not stepped openings. A stepped opening may be provided inthat the initial opening is made in a stepped fashion (for example usingtwo drills of different diameters), or by a self-cutting structure ofthe protecting element itself, that then may for example also advanceduring the augmentation process to prevent all of the sonotrode with thepossible exception of the most distal portion from getting into contactwith the bone tissue.

A protecting element 96 could optionally be segmented in acircumferential direction and then optionally project further to thedistal side, for example down to the bottom of the opening. Thereby, itlocally masks the bone tissue and causes segmented augmentation. In thisvariant, the set-up of FIG. 20 is a further embodiment of the methodaccording to its first aspect.

In an even further embodiment, a protecting element 96 serving as a maskcould have a geometry of the kind illustrated for the augmentationelement in FIGS. 14 and 15, i.e. include a body with a plurality ofopenings, especially in a segmented manner, i.e. comprising, as afunction of the azimuthal angle, sections with openings and sectionswithout openings. The openings in this even further embodiment mayconstitute a substantial portion of the surface of the element's convexhull, i.e. the empty spaces may constitute a substantial portion of forexample at least 50%, at least 60% or at least ⅔ of the surface of animaginary cylinder of which the protecting element 96 forms thenon-empty portions.

In all embodiments with a protecting element, (that may in someembodiments, as mentioned, serve as mask) the material of the protectingelement may be a metal or a ceramic material. Because the surface ofsuch material is repellant for liquefied thermoplastic material, thepolymer will only weakly adhere to the protecting element so that thelatter may be relatively easily be removed. This is even the case inconfigurations of the above-mentioned kind with openings through whichthe polymer material gets to the bone tissue—if the thickness of theprotecting element is sufficiently thin, for example having a thicknessof 0.1 mm or less.

In all embodiments with a protecting element, the protecting element mayoptionally be provided with an axial slit so that after removal of theshaft it may be radially collapsed and/or peeled off for removal.

The embodiments of FIG. 20 in addition may have the following optionalfeatures:

-   -   the distal foot 6 that for example may protect a nerve        underneath the initial opening;    -   weakening grooves at the outside of the augmentation element 1.

In addition or as an alternative to protection from friction, an outerprotection element 96 as shown in FIG. 20 may also serve other purposes.Especially, it may protect from heat conducted in the elementsencompassed by the protection element 96. In addition, or as analternative, it may itself take part in the energy conduction, forexample by serving as a (ground) electrode for conducting electricityfor the purpose of heating from the auxiliary element through the tool 3or directly the augmentation element.

According to yet another approach, the augmentation process may becombined with measures to deflect mechanical oscillations. A firstapproach is schematically illustrated in FIG. 21. FIG. 21 depicts adevice 101 for deflecting mechanical oscillations including an elongateand bent oscillation element 102, so that the oscillation element 101when excited to oscillate transversally at a coupling-in pointoscillates transversally at a coupling-out point. The coupling-in pointincludes an input terminal 103 (that may be coupled to an oscillationsource), and at the coupling-out point an output terminal 104 is formed,wherein a is provided with a sleeve-like terminal 104 that may eitherserve as the sonotrode (or a part thereof) or that may define aninterface to the sonotrode. An auxiliary element that guides theaugmentation element during the process may be guided in the center ofthe sleeve-like terminal 104. The device 101 at the region of the outputterminal 104 may also include a through opening (cannulation) throughwhich the auxiliary element may project and be held from its proximalside. While the embodiment of FIG. 20 does not readily allow for activeapplication of a counter-force to the applied force by which thesonotrode is pressed against the distal direction, such activecounter-force may not be necessary in cases where the tissue has enoughstrength to provide sufficient resistance.

Yet another approach is depicted in FIG. 22. FIG. 22 illustrates adeflection device 101 that has a ring-shaped resonating body. The anglebetween the coupling-in port and the coupling-out point is an integerfraction of 360°. The coupling-out terminal 104 may again besleeve-like. The auxiliary element 2 may be passively guided in aninterior of the sleeve-like terminal 104. It may also be held by (notshown) elements that grip the auxiliary from outside of the planedefined by the ring-shaped resonating body.

A variant of the embodiment of FIG. 22 is shown in FIG. 23. In contrastto the embodiment of FIG. 22, the coupling-out terminal 104 is attachedto the inside of the ring and to its proximal (upper) portion.

In a variant of the embodiment of FIG. 23, the ring-shaped resonatingbody may be closed. The coupling-out terminal 104 may then projectthrough a bore in the ring.

A further possibility of deflecting mechanical oscillations forinputting energy to liquefy at least portions of the augmentationelement is shown in FIG. 24. FIG. 24 very schematically illustrates a“rearward” configuration, i.e. a configuration in which a tensile forceis coupled into the tool—namely, the sonotrode 3—while energy is coupledinto the tool and from there into the augmentation element 1.

In this configuration, the sonotrode has a distal broadening 92 (foot)that has a proximally facing coupling-out face that during the couplingof energy into the augmentation element 1 interfaces with a distalcoupling-in face of the augmentation element 1. The sonotrode inaddition has a cable 8 through that is connected to the distalbroadening 92 and that connects the latter to a vibration source that inFIG. 24 is encased in the housing of a vibration generating apparatus401. The cable 8 may, for example, be connected to a vibrationgenerating module within the apparatus 401, which vibration generatingmodule includes an ultrasonic transducer and is shiftable inside thehousing so that during the process the cable can be pulled in thehousing thereby pulling the distal broadening 92 towards the housing.

For deflecting the mechanical oscillations, the arrangement includes adeflection structure that in the depicted embodiment includes a mountingprotrusion 402 with a deflection wheel 403 rotatingly mounted thereto.The counter element 2 (auxiliary element) is, in the embodiment of FIG.24, also directly mounted to the housing of the apparatus 401. Foraugmentation, the arrangement with the apparatus 401, sonotrode 8, 92and the augmentation element is positioned relative to the tissue sothat the distal broadening 92 and, at least partially, the augmentationelement 1 are placed in the tissue opening, and then the distalbroadening is retracted towards a proximal direction by pulling thecable 8 while mechanical vibrations are coupled into the latter. Thedeflection structure serves for deflecting the mechanical vibrations byan angle that in the depicted configuration is at least approximatelydefined by the structure of the apparatus 401 with the counter element2.

A configuration as illustrated in FIG. 24 may, for example, like thepreviously discussed concept, be advantageous for accessing tissueopenings that would be difficult to access by an arrangement withmovements only along a particular axis being possible, for examplecavities resulting after a tooth extraction.

FIG. 24 also shows the deflection angle α (in this text, the deflectionangle is defined in a manner that a deflection by 180° is nodeflection).

In the variant of FIG. 25, the counter element 2 is not mounted to thehousing of the apparatus but is a separate part. In this configuration,the operator (surgeon, dentist) needs to position two different parts(namely, the apparatus and the counter element) but can choose thedeflection angle freely and can vary it during the process. Thedeflection unit including the deflection wheel 403 may be mounted to thehousing of the apparatus (may be part of the apparatus) or may be aseparate part.

In embodiments where the deflection unit belongs to the apparatus, isreadily possible to make the deflection unit extendible, i.e. to adjustthe distance between the housing 401 and the deflecting element (thewheel 403 in the depicted configuration).

As an alternative to using a wheel, also a deflection edge, for examplewith a cable guiding channel may be used.

FIG. 26 schematically illustrates using a radiation source for couplingenergy into the augmentation element 1 for the step of impinging theaugmentation element with energy while the same is subject to a pressingforce. To this end, the tool 3 is chosen to be a glass cylinder intowhich radiation is coupled from the proximal side. The auxiliary element2 includes a foot interfacing with the distal end face of theaugmentation element. The light coming in through the tool 3 may beabsorbed at the distal end 301 of the tool 3, by the augmentationelement (reference number 302), or at the surface 303 of the foot at theinterface to the augmentation element.

FIG. 27 shows an example of electricity conducted through theaugmentation element 1 (which then includes an electrically conductingmaterial with a relatively low conductivity). To this end, the tool 3includes a first electrode 311 at the interface to the augmentationelement 1 and the auxiliary element 2 includes a second electrode 312 atthe interface to the augmentation element.

As an alternative, the tool 3 could be provided with a resistance heatercapable of heating the interface to the augmentation element. Note thatthis is possible both in a forward configuration with a tool 3 as shownin FIG. 27 as well as in rearward configurations with a tool having theshape of the auxiliary element 2 of FIG. 27 and with a counter elementfor exerting a counter force, the counter element example having theshape of the tool of FIG. 3.

The configurations in FIGS. 26 and 27 may be symmetric about the axis204 or may be formed as in examples of the hereinbefore described kind,especially in examples of segmented augmentation. The principle ofradiation or electricity as energy source is further also applicable toother embodiments of the invention taught herein.

What is claimed is:
 1. A method of augmenting hard tissue and/or hardtissue replacement material method comprising the steps of: providing aninitial opening in the hard tissue and/or hard tissue replacementmaterial; providing a thermoplastic augmentation element and a tool;placing the augmentation element in the initial opening, placing thetool in contact with a face of the augmentation element and pressing thetool against the face while energy is coupled into the tool and while aperiphery of a liquefaction interface of the tool and the augmentationelement is within the opening; thereby liquefying material of theaugmentation element at the liquefaction interface(s) to yield liquefiedmaterial; causing portions of the liquefied material to penetrate intostructures of the hard tissue and/or hard tissue replacement material;allowing the liquefied material to harden and to thereby becomeaugmentation material; and removing the tool; wherein at least one ofthe following conditions is fulfilled: a. in at least one axial depth,the augmentation element is segmented as a function of thecircumferential angle so that at this axial depth the circumferentialwall of the initial opening in first regions is in contact with theaugmentation element and in second regions is not in contact with theaugmentation element; b. in at least one axial depth of a resulting,augmented opening, the augmentation material is caused to be segmentedas a function of the circumferential angle; c. in a resulting, augmentedopening, the augmentation material is provided in at least two augmentedregions axially spaced from each other, wherein between the twoaugmented regions there is a non-augmented region; d. the augmentationelement does not have the symmetry of a rotational cylinder but isasymmetric with respect to rotation around any axis.
 2. The methodaccording to claim 1, wherein in the step of pressing the tool againstthe face, the tool is pressed into a distal direction.
 3. The methodaccording to claim 2, wherein the augmentation element is guided by anauxiliary element during the step of pressing the tool towards a distaldirection.
 4. The method according to claim 3, wherein the auxiliaryelement comprises a distal foot, wherein during the step of pressing thetool towards a distal direction, the auxiliary element is compressedbetween the tool and the foot, and wherein after the step of causingportions of the liquefied material to penetrate into structures of thehard tissue and/or hard tissue replacement material, the auxiliaryelement is removed.
 5. The method according to claim 3, wherein theauxiliary element has a non-circular cross section, and wherein asub-assembly consisting of the auxiliary element and the augmentationelement has a circular cross section.
 6. The method according to claim3, wherein the auxiliary element forms at least 60° of an outer contourof a sub-assembly consisting of the auxiliary element and theaugmentation element in a cross section perpendicular to a proximodistalaxis.
 7. The method according to claim 1, wherein the augmentationelement comprises a plurality of separate augmentation element parts. 8.The method according to claim 1, wherein the tool is a sonotrode andwherein in the step of pressing while energy is coupled into the tool,mechanical vibration energy is coupled into the tool.
 9. A method ofaugmenting hard tissue and/or hard tissue replacement material,comprising the steps of: providing at least one thermoplasticaugmentation element; placing the augmentation element in contact withthe hard tissue and/or hard tissue replacement material and causingmechanical energy to impinge on the augmentation element to liquefy atleast portions of the augmentation element and causing liquefiedaugmentation material portions of the augmentation element to penetrateinto the hard tissue and/or hard tissue replacement material; lettingthe liquefied augmentation material portions re-solidify; and removing aportion of the hard tissue and/or hard tissue replacement material andof the re-solidified augmentation material to yield an augmentedopening, the augmented opening having surface portions of the hardtissue and/or hard tissue replacement material with the re-solidifiedaugmentation material and having surface portions of the hard tissueand/or hard tissue replacement material without the re-solidifiedaugmentation material.
 10. The method according to claim 9, comprising,prior to the step of causing liquefied augmentation material topenetrate into the hard tissue and/or hard tissue replacement material,providing an initial opening of a geometry different from the geometryof the augmented opening.
 11. The method according to claim 10, whereinthe step of causing liquefied augmentation material to penetrate intothe hard tissue and/or hard tissue replacement material comprisescausing the liquefied material to penetrate into lateral walls of theinitial opening, wherein the augmentation element has a non-circularsymmetry.
 12. The method according to claim 9, wherein the step ofremoving a portion of the hard tissue and/or hard tissue replacementmaterial and of the re-solidified augmentation material is a step ofmaking an opening in the tissue, at a surface of which opening a part ofthe augmentation material is present.
 13. A method of augmenting hardtissue and/or hard tissue replacement material, comprising the steps of:providing an initial opening in the hard tissue and/or hard tissuereplacement material; providing a thermoplastic augmentation element,and further providing a tool and an auxiliary element; placing theaugmentation element in the initial opening, the augmentation element atleast partially encompassing a guiding portion of the tool or of theauxiliary element, coupling a pressing force and energy into the tooland from the tool into the augmentation element while a portion of theaugmentation element is within the opening and in contact with the hardtissue and/or hard tissue replacement material; thereby liquefyingmaterial of the augmentation element to yield liquefied material;causing portions of the liquefied material to penetrate into structuresof the hard tissue and/or hard tissue replacement material and/or intostructures of an element connected to the hard tissue and/or hard tissuereplacement material; allowing the liquefied material to harden and tothereby become augmentation material; and removing the tool; wherein atleast one of the following conditions is fulfilled: A. during the stepof coupling a pressing force and energy into the tool, an outerprotection element at least partially encompasses the tool and locallyprevents the tool from being in contact with the hard tissue and/or hardtissue replacement material; B. the augmentation element is generallysleeve-shaped and comprises at least one indentation or hole in a sleevewall; C. during the step of coupling a pressing force and energy intothe tool, in a telescoping region a portion of the tool encompasses aportion of the auxiliary element or a portion of the auxiliary elementencompasses the tool, wherein at least one of the tool and of theauxiliary element comprises at least one protrusion facing to the otherone of the tool and the auxiliary element, whereby in the telescopingregion a contact between the tool and the auxiliary element at locationsdifferent from the at least one protrusion is prevented; D. during thestep of coupling a pressing force and energy into the tool, the tool ispressed towards the distal direction, and wherein the tool comprises adistal broadening forming an salient feature that prevents a contactbetween the tool and the hard tissue and/or hard tissue replacementmaterial at locations proximally of the salient feature; E. prior to thestep of coupling a pressing force and energy into the tool, theaugmentation element is connected to the tool by an axial positive-fitconnection, and during the step of coupling a pressing force and energyinto the tool, the auxiliary element is pressed against a distaldirection to activate the step of liquefying material of theaugmentation element and to push portions of the liquefied materialaside and into the structures of the hard tissue and/or hard tissuereplacement material.
 14. The method according to claim 13, wherein atleast condition A. is fulfilled, wherein the protection elementcomprises a tap for cutting a thread.
 15. The method according to claim13, wherein at least condition B. is fulfilled, wherein the augmentationelement is generally sleeve-shaped.
 16. The method according to claim13, wherein at least condition C. is fulfilled, wherein at a distal endof the tool any remaining gap between the tool and the auxiliary elementhas a width of 0.2 mm or less.
 17. The method according claim 13,wherein at least condition E. is fulfilled, wherein the tool has athreaded outer surface portion, and wherein the threaded outer surfaceportion is encompassed by the augmentation element.
 18. The methodaccording to claim 13, wherein the energy is coupled into the tool inthe form of mechanical vibrations.
 19. The method according to claim 13,wherein the augmentation element is generally sleeve-shaped.
 20. Themethod according to claim 13, wherein the auxiliary element comprises aguiding shaft, wherein during the step of coupling a pressing force andenergy into the tool at least a portion of the augmentation element atleast partially surrounds the guiding shaft and the tool is arrangedproximally of the augmentation element at least partially surroundingthe guiding shaft, wherein the tool comprises the protrusion facingradially inwardly towards the guiding shaft.
 21. The method according toclaim 20, wherein the protrusion is arranged at a distal end of thetool.
 22. The method according to claim 20, wherein the augmentationelement is sleeve shaped with at least a portion of the auxiliaryelement completely surrounding the guiding shaft, and wherein the toolis sleeve shaped with a distal portion completely surrounding theguiding shaft.
 23. The method according to claim 22, wherein theprotrusion is an inwardly facing ridge.
 24. The method according toclaim 20, wherein the protrusion is an inwardly facing annular ridge.25. The method according to claim 20, wherein in the step of coupling apressing force and energy into the tool, the tool is pressed towards adistal direction against a proximal end face of the augmentationelement.
 26. The method according to claim 20, wherein the tool has atapered distal end surface.
 27. The method according to claim 20,wherein the protrusion is one-piece with other portions of the tool. 28.The method according to claim 20, wherein the tool is a sonotrode andwherein the step of coupling a pressing force and energy into the toolcomprises coupling mechanical vibration energy into the tool.
 29. Themethod according to claim 25, wherein the auxiliary element has a distalfoot forming a proximally-facing shoulder and, whereby the augmentationelement is clampable between tool and the distal foot.